Clinical amnagement of edentulous maxillectomy pt/ implant dentistry course

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2. CLINICAL MANAGEMENT OF EDENTULOUS MAXILLECTOMY PATIENT 2 INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com

3. CONTENTS • 1] Introduction • 2] Surgical Enhancements • 3] Phases Of Prosthetic Restoration  Surgical Obturator Prosthesis  Bone Screw Retention  Suture Retention  Circumzygomatic Wire Retention  Use Of The Existing Maxillary Denture • 4] Interim Obturator Prosthesis • 5] Definitive Obturator Prosthesis • 6] Lid Fabrication Of Hollow Obturator Prostheses • 7] Troubleshooting The Obturator Prosthesis  Leakage Into The Nose  Hypernasal Speech • 8] Conclusion • 9] References • 3www.indiandentalacademy.com

4. G.P.T-8 • maxillofacial prosthetics : the branch of prosthodontics concerned with the restoration and/or replacement of the stomatognathic and craniofacial structures with prostheses that may or may not be removed on a regular or elective basis 4www.indiandentalacademy.com

5. Introduction • Tumors of the hard palate, maxillary sinus, and sometimes the buccal mucosa or nasal cavity require surgery called a maxillectomy or maxillary resection. The hard palate is the anatomic floor of the maxillary sinus. • Depending on the extent of the tumor, maxillary resections can be performed that do not violate the integrity of the hard palate. Maintaining the hard palate however, is the exception rather than the rule. 5www.indiandentalacademy.com

6. • Violation of the hard palate creates an anatomic defect that allows the oral cavity, maxillary sinus, nasal cavity, and nasopharynx to become one confluent chamber. • Lack of anatomic boundaries creates disabilities in speech and deglutition. Air, liquids, and food bolus escape from the oral cavity to exit the nares, making adequate oral nutrition difficult if not impossible. • . Speech becomes unintelligible due to hyper nasality distorting sounds that require impounding of air within the oral cavity. 6www.indiandentalacademy.com

7. Surgical Enhancements • Surgical enhancements have been suggested to prepare the defect for optimal prosthetic rehabilitation • Some procedures offer definite advantages; others have minimal influence on prosthetic function and primarily add a burden of time and perhaps morbidity to the surgical procedure, 7www.indiandentalacademy.com

8. Maintain as much hard palate as possible • Since the edentulous patient must rely on the remnant of the hard palate for primary retention, support, and stability the surgeon should be encouraged to resect only enough hard palate to allow adequate tumor margins. • The more ipsilateral premaxillary area that can be maintained, the more of a tripoding prosthetic effect that can be achieved • This adds, stability to the prosthesis, and the increased surface area will enhance retention. 8www.indiandentalacademy.com

9. Quality of retention depends on • Muscular control. • Size of surgical cavity • availability of tissue undercut around the cavity • Direct and indirect retention provided by any remaining teeth. 9www.indiandentalacademy.com

10. Skin graft the cheek flap. • In the classic maxillectomy the cheek is elevated away from the maxillary bones, and the pterygoid muscles and the bones are resected. • This leaves a denuded surface on the entire cheek flap, remnants of the pterygoid muscle bed, and soft palate musculature originating form the pharyngeal wall • If this area is allowed to heal by secondary intention, the healing time will extend many weeks with a bleeding surface. • Eventually the surface will be covered with respiratory epithelium migrating from the nasal cavity and nasopharynx. • This mucosa does not serve well as prosthesis-bearing tissue and is easily abraded. 10www.indiandentalacademy.com

11. • . Respiratory epithelium will also add to the mucous secretions that the patient must clean from the cavity • . A split-thickness skin graft can be placed over these denuded surfaces at the time of tumor surgery. • This graft will be prosthesis bearing in 10 to 14 days and after a few weeks of maturation can be aggressively cleaned and approximated by the prosthesis 11www.indiandentalacademy.com

12. • . Due to differential contracture of the skin graft and the mucosa of the oral cavity, a scar band will form along the lateral cheek at the junction of the skin graft with the remaining buccal mucosa, and in the pterygoid muscle area. • It has often been stated this scar band will aid retention because it is an anatomic undercut. 12www.indiandentalacademy.com

13. • This area can be quite mobile when the patient moves the mandible, however, and the changes in contour must be accommodated in the obturator impression. • constant motion of this minimal undercut in the lateral cheek usually makes this area of little use for retention. 13www.indiandentalacademy.com

14. • Many maxillofacial texts suggest that the placement of a skin graft will decrease the contracture of the cheek flap • . For practical purposes, one should view the skin graft as a sound prosthetic bearing surface that will not be easily abraded, does not secrete mucus, allows for vigorous cleaning of the defect, and may aid in retention. 14www.indiandentalacademy.com

15. Remove the inferior turbinate • . If the hard palate is resected to expose the nasal cavity, the inferior turbinate is also exposed. • If the tumor does not involve the nasal cavity, the inferior turbinate will likely not be resected. • Anatomically this structure is only millimeters above the cut edge of the hard palate and covered with respiratory epithelium. • Maintaining the inferior turbinate will preclude extending the medial wall of the obturator bulb into the nasal cavity 15www.indiandentalacademy.com

16. Skin graft the maxillary sinus walls. • When tumor involves the hard palate with minimal involvement of the maxillary sinus walls. • The hard palate will be resected and most of the bony wall of the sinus will remain intact. • These walls can be prepared during surgery to allow the bony undercuts to serve for retention or for vertical support to keep the prosthesis from rotating into the defect during mastication 16www.indiandentalacademy.com

17. • The sinus walls are covered with respiratory mucosa, which must be denuded and covered with a split-thickness skin graft. • Grafting the sinus walls stops formation of polypoid tissue and mucus generation within the sinus and allows the walls to become load-bearing areas. 17www.indiandentalacademy.com

18.  Phases of Prosthetic Restoration 18www.indiandentalacademy.com

19. Surgical Obturator prosthesis • Use of an immediate surgical obturator is less common for the edentulous patient than the dentate patient because of the seemingly invasive method of securing the prosthesis. • Methods • 1. palatal bone screw, • 2.sutures into the surrounding mucosa, • 3.andcircumzygomatic wires. 19www.indiandentalacademy.com

20. • Regardless of the method of securing the prosthesis, the procedures needed to fabricate the surgical obturator are identical • Generally a auto polymerizing resin or heat cured resin is used but not composite resins because of its brittle nature 20www.indiandentalacademy.com

21. Bone screw retention • The palatal bone screw can be placed through a midpalate hole predrilled through the acrylic resin baseplate in the midpalatal at the anterior peak of the palatal vault. • This position will allow placement of the screw into the vomer. • The hole should be drilled from the palate to the intaglio surface and angled posteriorly. 21www.indiandentalacademy.com

23. • . A 13 to 16 mm self-tapping screw should be used to ensure enough length to pass through the denture and achieve adequate bone retention. • This bone screws are usually titanium or stainless steel and are available in mandibular fracture armamentarium. • A small plug of tissue conditioner or polyvinylsiloxane over the head of the screw will keep the screw attached to the denture in the event the patient dislodges the denture during the postoperative period. • 23www.indiandentalacademy.com

24. Suture retention • In a previously irradiated patient, one might elect to use the suture technique to avoid placing a bone screw in the irradiated palate. • 2-0 silk sutures can be passed through six to eight predrilled holes in the lateral and anterior borders of the acrylic resin baseplate. • Each suture is secured with a knot against the denture flange in the middle of the suture and each one tagged with a hemostat. • The baseplate is then taken to the oral cavity and each suture passed through the soft tissue and tied. 24www.indiandentalacademy.com

26. • It is not necessary to suture across the soft palate for adequate retention and soft palate sutures are difficult to remove when the patient is in the clinic • . There will be slight prosthesis movement with this technique, but the packing will be secured and the prosthesis will not dislodge. 26www.indiandentalacademy.com

27. Circumzygomatic wire retention • Wires are passed over the zygomatic arch and threaded through two bilateral holes placed in the premolar area of the baseplate flange. • This technique is the most invasive and has greatest morbidity when removing the wires in the clinical setting. • It is not commonly used. 27www.indiandentalacademy.com

28. • The palatal bone screw offers the most stability of the three options, The bone screw, sutures, and packing can be removed with sedation, • Syncopal attack is un avoidable if patient is sedated or not 28www.indiandentalacademy.com

29. Use of the existing maxillary denture • Some texts suggest using the patient's existing denture for the surgical obturartor and for the subsequent interim obturator prosthesis, • 29www.indiandentalacademy.com

30. Dis-advantages • 1. The patient will expect it to be used throughout the entire prosthetic period, • 2. When the surgical defect involves approximately one half of the hard palate, maintaining comfortable occlusion while constantly reducing and relining the flanges of an unstable obturator prosthesis is almost impossible. • 3. If the maxi1lary denture is ill -fitting preoperatively, it will be necessary to reline the denture prior to surgery 30www.indiandentalacademy.com

31. • As facial contracture occurs, the anterolateral border of the denture will require significant reduction . • It is not uncommon that the contracture is so great that the anterior teeth are soon extended beyond the obturator prosthesis periphery. • The teeth on the surgical side often require facial reduction and ultimate removal from the baseplate due to overextension. • If the teeth are not reduced, the lip is too protruded and unseats the prosthesis. 31www.indiandentalacademy.com

32. Interim Obturator Prosthesis • Chairside impression of the surgical site 5 to 10 days after surgery : • The baseplate used for the surgical obturator can be relined and modified to serve as the interim prosthesis • The baseplate can be border molded and relined on the remaining hard palate. 32www.indiandentalacademy.com

35. • After this is accomplished and the base is stable, the periphery of the surgical detect is impressed. • True-soft can be placed incrementally along the periphery of the defect. • Using this incremental shaping method creates a hollow, light prosthesis 35www.indiandentalacademy.com

36. Patient movements, speech, and swallowing evaluation during border molding • The impression, of the surgical side requires that the patient perform exaggerated head movements turning right to left with the head level • and then again with the neck flexed and extended. • The mouth should be opened and closed and the mandible moved laterally. • The patient should also be asked to swallow. • The clinician should maintain control of the impression throughout the entire procedure by manually supporting the tray 36www.indiandentalacademy.com

37. • Swallowing and head movements should always be made with every addition of material. • If the clinician does not use functional border molding, the prosthesis will be less stable and the patient will experience tissue irritation in a short time. 37www.indiandentalacademy.com

38. • The peripheries of the bulb portion will likely be 2 to 3 cm in height. There is no need to add material to fill the entire sinus space; it only adds weight to the prosthesis and offers little to the border seal. 38www.indiandentalacademy.com

39. • To achieve border seal and adequate speech restoration , the posterior border will be extended over the cut edge of the soft palate to extend to the posterior aspect of the defect. 39www.indiandentalacademy.com

40. • the only speech sounds that are formed when air passes through the nasal cavity are m, n, and ng, • When air is obstructed from passing from the vocal cords out the nose during the m, n, and ng sounds, hyponasal speech is evident, • This occurs frequently during the common cold when the nasal passages become obstructed from edema or mucus. 40www.indiandentalacademy.com

41. • Hypernasal speech occurs due to loss of air from the oral cavity into the nasal cavity. • In the case of the maxillectomy patient, this loss of air occurs because of an anatomic defect in the hard palate. • Without the obturator, the loss of air into the nasal cavity is so great that a patient's speech is Unintelligible 41www.indiandentalacademy.com

42. • Examining the peripheral surface of the obturator bulb and ensuring peripheral tissue contact will correct hypernasal speech in most instances • Final analysis for appropriate speech is to listen for distinction between the letters m and b. 42www.indiandentalacademy.com

43. • The patient should also say the Word beat then manually occlude the nares and again say the word beat. If there is a difference in Sound quality between the two test words, hypernasality remains • If the speech is still slightly hypernasal, a slight addition of a light or less viscous mix of material at the soft palate junction should be attempted. 43www.indiandentalacademy.com

44. • The fit may also be tested while drinking water with the head upright. • The liquid should pass easily without the patient experiencing reflux. into the nose or sinus cavity • Patients may not be able to control liquids in the oral cavity at the early interim phase, and drooling due to postoperative swelling and anesthesia of the upper lip on the surgical side from loss of the ipsilateral anterior-superior alveolar nerve is often observed.. 44www.indiandentalacademy.com

45. Insertion Of the interim prosthesis • After the tissue conditioner impression the entire tray and impression can be used as a wax pattern. • It can be flasked, completely removed from the stone mold, and the mold packed. auto polymerizing or heat-processed resin • prosthesis may be hollowed further to decrease weight 45www.indiandentalacademy.com

48. • The goal is to have a well fitting light weight prosthesis. • The prosthesis should be delivered within .a few hours of making the impression, 48www.indiandentalacademy.com

49. • The patient should be instructed not to leave the prosthesis out for more time than is needed to clean it or the surgical site, • At delivery of the prosthesis, the intaglio surface of the remaining hard-palate area and cut edge of the hard-palate area should be checked with pressure-indicating paste, 49www.indiandentalacademy.com

50. • The tissue conditioner is placed and functional impression is made. • Patients must regularly use a powdered adhesive to retain the prosthesis, so changing the tissue conditioner to acrylic resin in the interim prosthesis allows use of the adhesive on the hard palate area. 50www.indiandentalacademy.com

52. Revisions • Every 10 to 14 days the next 2 months, the prosthesis will require revisions due to tissue changes will be happening in the surgical site. 52www.indiandentalacademy.com

53. • Patients should be advised that adjustments are needed if pain or bleeding occurs or if the prosthesis will not seat. However, they should be reassured that increased hypernasality and nasal reflux is primarily a nuisance; there will be no physical or medical complications . 53www.indiandentalacademy.com

54. • The prosthesis should be evaluated to determine if the prosthesis will seat completely and not move with jaw and head movements. • If movement of the mandible creates movement of the prosthesis after border reduction, more material should be reduced in the overextended areas. • Some visits may require removal of considerable bulk of existing material due to tissue contraction 54www.indiandentalacademy.com

55. • When the' surgical site becomes more stable, then fewer major adjustments needed 55www.indiandentalacademy.com

56. • DEFINITIVE OBTURATOR PROSTHESIS 56www.indiandentalacademy.com

57. Preliminary impression • The preliminary impression should offer maximum extension within the surgical site. • When maxillary surgical cavity is, large, regardless of the tissue or bony undercuts within the cavity, it is not necessary to block the cavity with gauze prior to the impression. • Blocking of the defect adds time and patient discomfort, and the material often shifts during the impression, 57www.indiandentalacademy.com

60. • It is important to block palatal fistulas that open into intact maxillary sinus or nasal cavities. • Impression material can mushroom into the intact cavities and tear from the impression during removal of the tray. • This is most likely to occur with alginate impression materials 60www.indiandentalacademy.com

61. Final impression • The custom acrylic resin tray should extend 2 to 3 mm into the cavity. • It should extend beyond the scar band and superior to the cut edge of the hard and soft palates, leaving space for 5 to 8 mm of compound to add to the surgical site. • There may be cast undercuts within the surgical cavities which must be blocked out 61www.indiandentalacademy.com

62. • The remaining palate should be impressed first. The borders and cut edge of the palate should be border molded and then impressed with a definitive impression material. • Performing this initial step creates a stable tray for the addition of the cavity impression Compound ,this should be added incrementally to the periphery of the surgical side 62www.indiandentalacademy.com

63. • The cavity is convex from inferior to superior. At the height of the convexity, the cavity walls begin to turn toward the center of the cavity. • At this point the superior aspect of the prosthesis bulb should terminate. Superior extension beyond the greatest convexity adds weight to the prosthesis but adds no retention. 63www.indiandentalacademy.com

64. • It should be border moulded with impression wax with incremental addition. • A posterior palatal seal can also be placed. 64www.indiandentalacademy.com

65. Jaw relationship records • Maxillectomy patients have loss of facial contour on the surgical side proportional to the amount of bone that is resected • Infrastructure maxillectomies have minimal facial disfigurement. 65www.indiandentalacademy.com

73. • if the floor of the orbit is resected, the globe is also displaced. • Often the maxillary resection crosses the midline, and if the nasal spine is resected, the nose· is unsupported There is a desire to use the obturator prosthesis to support the facial tissues. • Unfortunately these tissues are fibrotic and can only be minimally displaced by the prosthesis border. • Trying to push the contracted tissues into their preoperative position can cause overextension of the prosthesis borders. • This creates considerable dislodging force on the prosthesis 73www.indiandentalacademy.com

74. • Attempting to maintain the dentition in its normal position will cause dislodging forces. • Normal prosthetic landmarks cannot be used to position the dentition. • Processed record bases are ideal for jaw relationship records for the maxillofacial prosthetic patient. Because of the missing structures and unusual reconstructions, prosthetic retention and stability are greatly compromised. 74www.indiandentalacademy.com

75. • Blocking out routine undercuts and the undercuts within the surgical area adds to the instability of the conventional record base. • Blocking out these undercuts will result in a trial base that does not extend to the periphery or the defect • This trial base makes no Contact with the surgical side of the face. • There will be no retention of the prosthesis except for the adhesive on the hard palate. • The prosthesis will fall into the oral cavity when attempting to establish the occlusal plane and rotate into the defect when attempting the centric relation record. 75www.indiandentalacademy.com

76. • Without maximum extension of the record one cannot determine the optimal position of the teeth to support the lip and cheek. • It is quite common that retention becomes worse as the wax rim is added in its preoperative position • A Compromise must be reached between tissue support and prosthesis retention. 76www.indiandentalacademy.com

77. • The wax up of the processed obturator base can be solid in the area of the bulb and hollowed before jaw relationship records. • The bulb can be processed hollow by waxing the external periphery of the bulb portion several millimeters thick and pouring a stone core through the back of the master cast or creating a stone core in the cope of the cast, in which case there will be a hole in the palate after processing 77www.indiandentalacademy.com

78. • The jaw relationship appointment should progress as a routine denture appointment. • At the try-in appointment, all records are verified • For the patient edentulous in both arches, a cuspless tooth allows freedom to create a negative horizontal overlap on the surgical side of the arch without having to create it on the nonsurgical side 78www.indiandentalacademy.com

80. • The final palatal contours should be evaluated at the try-in appointment. It is likely that the contours are not symmetric because they were created arbitrarily on the surgical side • The vault may be too high or too flat. • Finally, pressure indicating paste can be streaked across the palate from right to left. ‘ • Seat the prosthesis and have the patient swallow and count. • Where the tongue makes contact with the palate, the contact can be read in the pressure-indicating paste. • Heavy areas should be reduced and the entire palate checked again. • Wax may need to be added in the palate where there is no contact. 80www.indiandentalacademy.com

81. • If the patient lisps, air is escaping laterally from the tongue. • Because the teeth are positioned palatally due to facial contracture, they may impinge on the tongue • Prosthesis can be processed at a lower temperature than that used to process the base. • The clinical significant of the distortion created with multiple processing of the resin is negligible 81www.indiandentalacademy.com

82. • The clinician may place a lid on the obturator prosthesis or may insert the prosthesis with the bulb open for several days until 'all of the adjustments are performed. 82www.indiandentalacademy.com

83. Insertion • At insertion, the prosthesis should be evaluated for pressure areas as described for interim prostheses, including pressure- indicating paste for the residual palate 83www.indiandentalacademy.com

84. Instructions • Patients should continue to wear the maxillary prosthesis or the interim prosthesis at night because sinus secretions and saliva cannot be managed at night without it. • If the prosthesis is removed overnight, the soft tissue periphery of the surgical site will change due to tissue edema, • and patients will report that it often requires an hour of wearing the prosthesis in the morning before it fully seats into position 84www.indiandentalacademy.com

85. • Mastication is also often difficult for patients with large surgical defects and must be accomplished on the nonsurgery side of the arch. 85www.indiandentalacademy.com

86. Lid fabrication of hollow obturator prostheses • It will difficult for the patient to clean the inside area if the bulb is left open and if it is not smooth • Placing a lid on the bulb allows hollowing of the alveolar area and into any unusual lateral undercuts 86www.indiandentalacademy.com

88. Other methods 88www.indiandentalacademy.com

90. • TROUBLESHOOTING THE OBTURATOR PROSTHESIS 90www.indiandentalacademy.com

91. Leakage into the Nose • Many patients eventually complain of nasal reflux and hypernasal speech caused by escape of air. • This may occur several months or even a few years after insertion of the prosthesis. • In most cases, continued fibrosis in the tissues bordering the prosthesis is the cause. 91www.indiandentalacademy.com

92. • The prosthesis should be disclosed with a tissue-conditioning material, and the patient should perform functional movement. • If swallowing and speech improve, the disclosing material should be evaluated for the area where the tissue conditioner is thickest. • The speech can be tested by evaluating the m and b sounds and the word. beat as described previously, 92www.indiandentalacademy.com

93. • The tissue condition material should be checked to see where this reline is required and this conditioning material is replaced with reline material later. 93www.indiandentalacademy.com

94. Hypernasal Speech • Patients may complain of hypernasal speech at follow-up visits • This is because of the continued fibrosis through years and the dysfunctions of the soft palate and pharyngeal closure mechanism. • For this a pharyngeal obturator must be constructed where a small amount of soft palate is also resected • . Some patients are unable to seat the prosthesis because of its unusual path of insertion. • If this procedure is unsuccessful, the hyper nasal speech cannot be prosthetically corrected 94www.indiandentalacademy.com

95. conclusion • The edentulous obturator patient has greater problems in retention, speech and mastication than the conventional maxillary denture patient • . Finally, no matter what additional retentive elements may be employed sound prosthodontic principles of using bony undercuts achieving maximum tissue coverage without overextension, and placing the dentition in harmony with the functional tissue are paramount for prosthetic success when treating the edentulous maxillectomy patient. 95www.indiandentalacademy.com

96. • NEED IS MOTHER OF ALL INVENTIONS 96www.indiandentalacademy.com

97. References • 1] CHELIAN, multi disciplinary practice • 2] JOHN BUMER maxillo facial rehabilitation • 3] THOMAS. D .TAYLOR . clinical maxillo facial prosthetics • 4] Paprocki Gj, Jocob RF, Kramer DC, seal integrity of hollow- bulb obturator. Int j prosthodont 1990,-3,- 457 97www.indiandentalacademy.com

98. References • 1] CHELIAN, multi disciplinary practice • 2] JOHN BUMER maxillo facial rehabilitation • 3] THOMAS. D .TAYLOR . clinical maxillo facial prosthetics • 4] Paprocki Gj, Jocob RF, Kramer DC, seal integrity of hollow- bulb obturator. Int j prosthodont 1990,-3,- 457 98 For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com

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